Addressing Burnout: A New Vision for Single Payer Health Reform

1. Introduction • What is “burnout” • Why relevant to single payer health reform • Both struggle to achieve, and vision for future • Contextualizing in current system issues • How viewing thru PNHP lens, helps us view differently from standard, status quo approaches • Particular experience, expertise of panelists • But most important is your views

2. Key Questions/Challenges • Won’t urging more activism/advocacy efforts further stress us and drain our energies? • Don’t single payer systems have just as much burnout as US? • How to deal with the fact that single payer is in distant future, yet burnout is real and now? • What’s wrong with resilience training, mindfulness training, better work-life balance approaches? • What about other healthcare workers; aren’t they also being burned out?

3. Making a Difference • A caring system: one that cares about patients and staff • One that is motivated and designed around care and caring rather than profits and markets. • Conceptualization of professionalism that is wrapped up with service, solidarity, satisfaction, and a rewarding sense that we are meaningfully making our patients and the system better as a result of our efforts

5. Big Ideas to Consider • Alienation* • 150 years’ old Marxist insight related to loss of ownership and connection to work process • Turning workers into interchangeable, dehumanized and dispensable parts of production process • Alienated from our work, our co-workers, the system • Lean • Management by stress • Purports to be antidote to Taylorism but often the same • Squeezing out every bit of “waste,” “slack” in name of efficiency *Yates, Nothing to Lose but our Chains. Monthly Review Oct 2018

6. “We’re spending our days doing the wrong work,” argues Christine Sinsky, a practicing internist and vice president for professional satisfaction at the American Medical Association, who has conducted several studies tracking how doctors spend their time. “At the highest level, we are disconnected from our purpose and have lost touch with the things that give joy and meaning to our work.” …. it is crowding out our true work as healers

7. Quality and its Discontents • Side effects of dysfunctional efforts to control costs • Lacking meaningful levers, must resort to stressful, wasteful, and ultimately futile methods that frustrate doctors and patients • “Outside-in” rather than “inside-out” quality • Failure to engage front line staff in meaningful rewarding quality improvement • Metrics • P4P, Utilization review, gaming measure Schiff chapter 3 in Medicine Under the Knife 2018

8. Adapting to the Suboptimal When told in late 1850’s by a recent visitor to the South that the slaves appeared to be happy and well adjusted,he is reported to have replied: Frederick Douglass Abolitionist, ex slave

9. Adapting to the Suboptimal When told in late 1850’s by a recent visitor to the South that the slaves appeared to be happy and well adjusted,he is reported to have replied: “Then it’s even worse than I thought.” Frederick Douglass Abolitionist, ex slave

10. EMR- Both a Cause and a Symptom • Fredrick Douglas quote- • Slaves are happy, content; “it’s even worse than I thought” • Story after story of failure, refusal to list to front line providers; monopoly power • No real time help • Sample pet peeve- can’t tell if patient(s) waiting • Indications Rx: 3x faster; 2x satisfaction • Epic no real interest • Scribes- workaround for poorly designed EMR’s* • Why subject the MA or pre-med to bad design *Schiff & Zucker. Medical Scribes: Salvation for Primary Care or Workaround for Poor EMR Usability? JGIM 2016

11. Working With and For Patients? • Antagonisms created • Lack of time • Taking out frustrating on each other • Structure of practice environment • Access barriers • Conflicting financial incentives, distrust • Enemies not Allies • Framing cost containment as blaming patients (overly-demanding), doctors (profligate ordering of tests, drugs) • Lack of respect for patients/MDs and clinical realities • Politically line up opposite sides • Malpractice reform. • Payment “reform”

12. Joy in Practice- Relationships • Doctors yearn for meaningful relationships with patients…..and visa versa* • Continually undermined by market insurance system • Boundaries: Powerful forces opposing joining hands, caring, personal, rewarding relationships • Our new study on patient boundaries • Emphasis on community, fun, playfulness, forgiving, empathy, solidarity • Struggling together: recharging, rejuvenating • Change agents, as a team *Hoff, Next in Line: Future of Primary Care 2017

13. NY Times 5/10/18

14. -Chief Medical Officer & Global Director of Healthcare Transformation, IBM-Director of the ACGME-“Godfather" of the Patient Centered Medical Home (PCMH) concept What patients want is a deep relationship with a healer…this is the foundation upon which we need to build healthcare Dr. Paul Grundy 14

15. What would a Good Day Look Like Having enough time w/ our patients Knowing our patients Having adequate time, support to practice conservatively Not being hassled, but rather helped by management EMR that is efficienct, Not feeling like in antagonistic relationships Not having to worry about hassle w/ billing, billing coding, co pays, problems getting what pt needs No disruptions in continuinty, insurance coverage Making a difference for each patient, as well as contributing to making system continuously better Learning, growing, improving together with patients

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18. Charity or Solidarity International solidarity is "not an act of charity but an act of unity between allies fighting on different terrains toward the same objectives." - Samora Machel "Unlike solidarity, which is horizontal and takes place between equals, charity is top-down, humiliating those who receive it and never challenging the implicit power relations." - Eduardo Galeano] 18

19. "Solidarity is not a matter of altruism. Solidarity comes from the inability to tolerate the affront to our own integrity of passive or active collaboration in the oppression of others, and from the deep recognition of our most expansive self-interest. From the recognition that, like it or not, our liberation is bound up with that of every other being on the planet, and that politically, spiritually, in our heart of hearts we know anything else is unaffordable." - Aurora Levins Morales 19

20. Solidarity is the integration, and degree and type of integration, shown by a society or group with people and their neighbors.[1] It refers to the ties in a society that bind people to one another. 20

21. "If you have come here to help me,  you are wasting your time.  But if you have come because your liberation is bound up with mine, then let us work together." • Lilla Watson Autralian Aborinal activist speaking to social workers 1985* *"not comfortable being credited for something that had been born of a collective process" and prefers that it be credited to "Aboriginal activists group, Queensland, 1970s 21

22. "Solidarity does not assume that our struggles are the same struggles, or that our pain is the same pain, or that our hope is for the same future. Solidarity involves commitment, and work, as well as the recognition that even if we do not have the same feelings, or the same lives, or the same bodies, we do live on common ground." - Sarah Ahmed 22

23. Kindness- A Duty or…. For Losers Jeffrey A duty of kindness Jl Royal Socy of Med 2016 ‘When I can think of nothing positive to write about in a reference for a junior doctor, I say she is kind,’ commented a colleague. Kindness has now been relegated to an attribute of losers rather than being an integral part of a doctor’s duty to a patient. 23